1
|
Morton A. Pregnancy complicated by neurological and neurosurgical conditions - The evidence regarding mode of delivery. Obstet Med 2022; 15:11-18. [PMID: 35444727 PMCID: PMC9014549 DOI: 10.1177/1753495x211000176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 09/21/2020] [Accepted: 02/10/2021] [Indexed: 11/15/2022] Open
Abstract
Neurological and neurosurgical conditions complicating pregnancy may precipitate considerable concern regarding the risk of complications, and uncertainty regarding the preferred mode of delivery and anaesthesia. Caesarean section is known to be associated with significantly increased risk of adverse maternal outcomes compared with vaginal delivery in healthy pregnancy. Nevertheless, a common perception exists among the general population and some health professionals that caesarean section is safer for the mother and baby in high-risk pregnancies. This manuscript examines the literature regarding the risks and outcomes related to mode of delivery in pregnancy complicated by disorders of the central nervous system. With the exception of women with raised intracranial pressure, and some women with Von Hippel-Lindau syndrome, the available evidence suggests that the mode of delivery should be based upon obstetric indications.
Collapse
Affiliation(s)
- Adam Morton
- Obstetric Medicine Department, Mater Hospital, South Brisbane,
Australia,Faculty of Medicine, University of Queensland, St Lucia,
Australia,Adam Morton, Mater Hospital, Raymond
Terrace,, South Brisbane, Brisbane, AU-QLD Queensland 4101, Australia.
| |
Collapse
|
2
|
Miller EC. Maternal Stroke Associated With Pregnancy. Continuum (Minneap Minn) 2022; 28:93-121. [PMID: 35133313 PMCID: PMC10101187 DOI: 10.1212/con.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women. RECENT FINDINGS Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life. SUMMARY Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.
Collapse
|
3
|
Azad HA, Prasad N, Shlobin NA, Mitra A, Cloney MB, Hopkins BS, Jahromi BS, Potts MB, Dahdaleh NS. Clinical Characteristics, Course, and Outcomes of Vertebral Artery Dissections in the Postpartum Period. Neurosurgery 2021; 89:792-799. [PMID: 34383947 DOI: 10.1093/neuros/nyab296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 06/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Postpartum vertebral artery dissections (ppVADs) are rare but potentially morbid conditions that occur in otherwise healthy patients. OBJECTIVE To evaluate clinical characteristics of ppVADs. METHODS Demographic, clinical, treatment, and outcome data were collected on ppVADs and are presented in a case series of 12 patients and compared to the general cohort. RESULTS In total, 12 patients had ppVADs in our cohort of 310 patients with vertebral artery dissections (VADs). They occurred 11.27 days (95% CI, -0.85 to 23.39) postdelivery. Of these, there were 5 (42%) with a hypertensive disorder of pregnancy, and 4 (33%) who had migraines. A total of 3 (25%) had ischemic strokes and 1 (8%) had a subarachnoid hemorrhage. In total, 2 patients (17%) had unfavorable modified Rankin Scale (mRS, 2-6) at discharge from hospital. Patients with ppVADs more often had bilateral VADs (42% vs 17%, P = .03), had pseudoaneurysms (50% vs 18%, P = .0068), were younger (33.83 years vs 44.32 years, P = .018), and had lower Charlson Comorbidity Index (CCI = 0 vs 0.99, P = .0038). Anticoagulant treatment was used in a similar percentage of patients. Multivariate analysis revealed 3 factors were predictive of change in mRS: CCI (OR = 1.09, 95% CI, 1.02-1.15), stroke (OR = 0.78, 95% CI, 0.65-0.95), and mRS at hospital discharge (OR = 0.80, 95% CI, 0.74-0.87). CONCLUSION There are only 15 isolated ppVADs reported in the literature; this study adds 12 patients with 17 ppVADs. Postpartum VADs occur in younger, healthier patients than in the general cohort, raising questions about mechanism of injury. The majority of ppVADs have good neurological outcomes.
Collapse
Affiliation(s)
- Hooman A Azad
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nikil Prasad
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Akash Mitra
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael B Cloney
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Benjamin S Hopkins
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
5
|
Shanmugalingam R, Reza Pour N, Chuah SC, Vo TM, Beran R, Hennessy A, Makris A. Vertebral artery dissection in hypertensive disorders of pregnancy: a case series and literature review. BMC Pregnancy Childbirth 2016; 16:164. [PMID: 27422677 PMCID: PMC4947248 DOI: 10.1186/s12884-016-0953-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 07/09/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Arterial dissection is a rare complication of pregnancy and puerperium. There have been reports of aortic, coronary and cervical artery dissection in association with preeclampsia, however, vertebral artery dissection is rarely reported particularly in the antenatal setting in the presence of a Hypertensive Disorder of Pregnancy (HDP).The general annual incidence of symptomatic spontaneous cervicocephalic arterial dissection is 0.0026 % and a data registry reported that 2.4 % of these occurred in the post-partum period. The actual incidence of vertebral artery dissection in HDP is unknown as the current literature consists of case series and reports only with most documenting adverse outcomes. Given the presence of collateral circulation, unilateral vertebral artery dissections may go unrecognised and may be more common than suspected. CASE PRESENTATION We present a case series of four patients with vertebral artery dissection in association with HDP, two of which occurred in the antenatal setting and two in the post-partum setting. All our patients had favourable outcome with no maternal neurological deficit and live infants. Our discussion covers the proposed pathophysiology of vertebral artery dissection in HDP and the management of it. CONCLUSION Our case series highlights the need to consider VAD an important differential diagnosis when assessing pregnant women with headache and neck pain particularly in the context of HDP.
Collapse
Affiliation(s)
- Renuka Shanmugalingam
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
- Western Sydney University, Penrith, Australia
- Vascular Immunology Research Group, Heart Research Institute, Newtown, Sydney Australia
| | - Nina Reza Pour
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Siang Chye Chuah
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Thi Mong Vo
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Roy Beran
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
| | - Annemarie Hennessy
- Campbelltown Hospital, Therry Road, Campbelltown, 2560 NSW Australia
- Western Sydney University, Penrith, Australia
- Vascular Immunology Research Group, Heart Research Institute, Newtown, Sydney Australia
| | - Angela Makris
- Liverpool Hospital, Elizabeth Street, Liverpool, 2170 NSW Australia
- Western Sydney University, Penrith, Australia
- University of New South Wales, Sydney, Australia
- Vascular Immunology Research Group, Heart Research Institute, Newtown, Sydney Australia
| |
Collapse
|
7
|
Mitchell LA, Santarelli JG, Singh IP, Do HM. Reversible cerebral vasoconstriction syndrome and bilateral vertebral artery dissection presenting in a patient after cesarean section. BMJ Case Rep 2013; 2013:bcr-2012-010521. [PMID: 23354867 DOI: 10.1136/bcr-2012-010521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset thunderclap headache and focal neurologic deficits. Once thought to be a rare syndrome, more advanced non-invasive imaging has led to an increase in RCVS diagnosis. Unilateral vertebral artery dissection has been described in fewer than 40% of cases of RCVS. Bilateral vertebral artery dissection has rarely been reported. We describe the case of a patient with RCVS and bilateral vertebral artery dissection presenting with an intramedullary infarct treated successfully with medical management and careful close follow-up. This rare coexistence should be recognized as the treatment differs.
Collapse
Affiliation(s)
- Lex A Mitchell
- Department of Radiology, Stanford University Medical Center, Stanford, CA, USA
| | | | | | | |
Collapse
|
8
|
Komotar RJ, Mocco J, Samuelson RM, Tawk RG, Siddiqui AH, Levy EI, Hopkins LN. Rapidly successive, symptomatic, bilateral, spontaneous vertebral artery dissections: treatment with stent reconstruction. ACTA ACUST UNITED AC 2009; 72:300-5. [PMID: 18514287 DOI: 10.1016/j.surneu.2008.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Accepted: 02/18/2008] [Indexed: 10/22/2022]
|
9
|
Tuluc M, Brown D, Goldman B. Lethal Vertebral Artery Dissection in Pregnancy: A Case Report and Review of the Literature. Arch Pathol Lab Med 2006; 130:533-5. [PMID: 16594746 DOI: 10.5858/2006-130-533-lvadip] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Subarachnoid hemorrhage represents a rare event in pregnancy with a high mortality rate. We present the case of a 39-year-old pregnant woman who developed right vertebral artery dissection with subsequent massive subarachnoid hemorrhage with fatal outcome. The macroscopic and microscopic autopsy findings are described. A review of the literature with a discussion of the varied predisposing factors for vertebral artery dissection and subarachnoid hemorrhage and the rarity of these events in pregnancy is provided.
Collapse
Affiliation(s)
- Madalina Tuluc
- Department of Pathology, Temple University Hospital, Philadelphia, PA, USA
| | | | | |
Collapse
|